<?xml version="1.0" encoding="UTF-8"?>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en" lang="en">
  <head>
    <title>新增HIV详细信息表</title>
    <meta http-equiv="keywords" content="enter,your,keywords,here" />
    <meta http-equiv="description" content="A short description of this page." />
    <meta http-equiv="content-type" content="text/html; charset=UTF-8" />
    <#include "/template/head.html">
    <script type="text/javascript" src="${basePath}js/common.js" charset="utf-8"></script>
    <script type="text/javascript"> 
    $.metadata.setType("attr", "validate");
    $(document).ready(function() {
      $("#hivbForm").validate();
    });
    </script> 
  </head>
  <body>
    <form id="hivbForm" action="${basePath}brxx/save.do" method="post">
      <table class="cmxform">
        <caption>新&nbsp;&nbsp;增&nbsp;&nbsp;HIV&nbsp;&nbsp;表</caption>
        <tr>
          <th width="12%">KICID号：</th>
          <td width="38%"><input name="kicid" value="${baseInfo.kicid}" class="disabled" readonly/></td>
          <th width="12%">病人姓名：</th>
          <td width="38%"><input name="brxm" value="${baseInfo.brxm!}" class="disabled" readonly/></td>
        </tr>
        <tr>
          <td colspan="4">
            <span style="color:blue">附表4填写说明：日期格式 yyyy-MM-dd；</span>
          </td>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>1、HIV实验首次检测为阳性是什么时间：</label>
            <input name="yxjcrq" class="Wdate date"/>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>2、你是否接受HIV治疗：</label>
            <span onclick="rotDis('zl', 'checked', [1], 'tb_zl_detail')">
              <input type="radio" name="zl" value="1"/>是
              <input type="radio" name="zl" value="2"/>否
              <input type="radio" name="zl" value="3"/>不详
            </span>
            <table id="tb_zl_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">2.1、你何时接受HIV治疗：</th>
                <td><input name="zlrq" disabled="disabled" class="Wdate date"/></td>
              </tr>
              <tr>
                <th width="20%">2.2、你接受过什么样的HIV治疗（参照抗逆转录病毒手册）：</th>
                <td><input name="zlqk" disabled="disabled"/></td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>3、你是否接受过HIV病毒读数实验：</label>
            <span onclick="rotDis('sy', 'checked', [1], 'tb_sy_detail')">
              <input type="radio" name="sy" value="1"/>是
              <input type="radio" name="sy" value="2"/>否
              <input type="radio" name="sy" value="3"/>不详
            </span>
            <table id="tb_sy_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">3.1、你最近一次实验为何时：</th>
                <td><input name="syrq" disabled="disabled" class="Wdate date"/></td>
              </tr>
              <tr>
                <th width="20%">3.2、你最近一次实验HIV病毒读数如何：</th>
                <td><input name="syqk" disabled="disabled"/></td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>4、你是否曾接受过T细胞/CD4计数实验：</label>
            <span onclick="rotDis('cd4', 'checked', [1], 'tb_cd4_detail')">
              <input type="radio" name="cd4" value="1"/>是
              <input type="radio" name="cd4" value="2"/>否
              <input type="radio" name="cd4" value="3"/>不详
            </span>
            <table id="tb_cd4_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">4.1、你最后一次T细胞实验是何时做的：</th>
                <td><input name="cd4rq" disabled="disabled" class="Wdate date"/></td>
              </tr>
              <tr>
                <th width="20%">4.2、你最最后一次CD4计数是多少：</th>
                <td><input name="cd4js" disabled="disabled" /></td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>5、你是否已被诊断为AIDS：</label>
            <span onclick="rotDis('aids', 'checked', [1], 'tb_aids_detail')">
              <input type="radio" name="aids" value="1"/>是
              <input type="radio" name="aids" value="2"/>否
              <input type="radio" name="aids" value="3"/>不详
            </span>
            <table id="tb_aids_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">5.1、你是何时被诊断的：</th>
                <td><input name="aidsrq" disabled="disabled" class="Wdate date"/></td>
              </tr>
              <tr>
                <th width="20%">5.2、你的AIDS诊断是什么：</th>
                <td><input name="aidszd" disabled="disabled"/></td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>6、出现结核病症状时最近的CD4检测结果：</label>
            <input name="zjcd4jg"/>
            <label>检测时间：</label>
            <input name="zjcd4rq" class="Wdate date"/>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>出现结核病症状时最近的HIV病毒读数：</label>
            <input name="zjhivjg"/>
            <label>检测时间：</label>
            <input name="zjhivrq" class="Wdate date"/>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>在结核病诊断时或结核病治疗期间去过医院或CDC：</label>
            <input type="radio" name="hiv61" value="1"/>是
            <input type="radio" name="hiv61" value="2"/>否
            <input type="radio" name="hiv61" value="3"/>不详
          </th>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>在诊断结核病之前接受抗逆转录病毒治疗：</label>
            <input type="radio" name="hiv62" value="1"/>是
            <input type="radio" name="hiv62" value="2"/>否
            <input type="radio" name="hiv62" value="3"/>不详
          </th>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>在诊断结核病时接受抗逆转录病毒治疗：</label>
            <input type="radio" name="hiv63" value="1"/>是
            <input type="radio" name="hiv63" value="2"/>否
            <input type="radio" name="hiv63" value="3"/>不详
          </th>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>在诊断结核病之前接受更高活性抗逆转录病毒治疗：</label>
            <input type="radio" name="hiv64" value="1"/>是
            <input type="radio" name="hiv64" value="2"/>否
            <input type="radio" name="hiv64" value="3"/>不详
          </th>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>在结核病诊断时接受更高活性抗逆转录病毒治疗：</label>
            <input type="radio" name="hiv65" value="1"/>是
            <input type="radio" name="hiv65" value="2"/>否
            <input type="radio" name="hiv65" value="3"/>不详
          </th>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>在结核病治疗过程中接受更高活性抗逆转录病毒治疗：</label>
            <input type="radio" name="hiv66" value="1"/>是
            <input type="radio" name="hiv66" value="2"/>否
            <input type="radio" name="hiv66" value="3"/>不详
          </th>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>7、HIV危险因素（选择所有的适宜项）：</label><br />
            <input type="checkbox" name="wxysnt" value="1"/> 男同性恋
            <input type="checkbox" name="wxysdp" value="1"/> 毒品注射
            <input type="checkbox" name="wxysyx" value="1"/> 异性性行为
            <input type="checkbox" name="wxysxy" value="1"/> 血液制品
            <input type="checkbox" name="wxyswcq" value="1"/> 围产期
            <input type="checkbox" name="wxyswqt" value="1"/> 不详
          </th>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>8、与HIV相关的机会型感染：</label><br />
            <input name="gr01"/><label>诊断日期：</label><input name="gr01rq" class="Wdate date"/><br />
            <input name="gr02"/><label>诊断日期：</label><input name="gr02rq" class="Wdate date"/><br />
            <input name="gr03"/><label>诊断日期：</label><input name="gr03rq" class="Wdate date"/><br />
          </th>
        </tr>
        <tfoot>
          <tr>
            <td colspan="4">
              <input type="hidden" name="curStep" value="hivb"/>
              <input type="hidden" name="chain" value="${chain}"/>
              <input type="hidden" id="action" name="action" value="forward"/>
              <button type="button" class="back" onclick="$('#action').val('reverse');$('#hivbForm').submit()"></button>&nbsp;&nbsp;&nbsp;
              <button type="button" class="next" onclick="$('#hivbForm').submit()"></button>
            </td>
          </tr>
        </tfoot>
      </table>
    </form>
  </body>
</html>
